What are the features of high-performing quality improvement collaboratives? A qualitative case study of a state-wide collaboratives programme

Objectives Despite their widespread use, the evidence base for the effectiveness of quality improvement collaboratives remains mixed. Lack of clarity about ‘what good looks like’ in collaboratives remains a persistent problem. We aimed to identify the distinctive features of a state-wide collaboratives programme that has demonstrated sustained improvements in quality of care in a range of clinical specialties over a long period. Design Qualitative case study involving interviews with purposively sampled participants, observations and analysis of documents. Setting The Michigan Collaborative Quality Initiatives programme. Participants 38 participants, including clinicians and managers from 10 collaboratives, and staff from the University of Michigan and Blue Cross Blue Shield of Michigan. Results We identified five features that characterised success in the collaboratives programme: learning from positive deviance; high-quality coordination; high-quality measurement and comparative performance feedback; careful use of motivational levers; and mobilising professional leadership and building community. Rigorous measurement, securing professional leadership and engagement, cultivating a collaborative culture, creating accountability for quality, and relieving participating sites of unnecessary burdens associated with programme participation were all important to high performance. Conclusions Our findings offer valuable learning for optimising collaboration-based approaches to improvement in healthcare, with implications for the design, structure and resourcing of quality improvement collaboratives. These findings are likely to be useful to clinicians, managers, policy-makers and health system leaders engaged in multiorganisational approaches to improving quality and safety.


A qualitative study of the Michigan collaborative quality initiatives
Interview topic guide

Research outputs
36.Why are the collaboratives able to publish so many of their results as research papers?
What infrastructure and relationships are in place to support this approach?How does it happen in practice?

Aim:
Identify the program theory of the Michigan CQIs, including identification of specific interventions and their contextual influences, in so doing characterising the mechanisms of their success.

qualitative study of the Michigan collaborative quality initiatives Interview topic guide
training required?Who receives training and how does that happen?15.Who are the key people responsible for ensuring the collaborative works effectively on a day-to-day basis?Are the systems they use to achieve this reliable?What are they?Data 16.What data are most relevant for the purposes of improving quality of care?Why?What process was used to prioritise data and what role did clinicians play in this? 17.How has data and its collection been standardized between participating hospitals?How did that process happen in practice?18.How are data collected in Michigan?19.Who is responsible for collecting data?What role do participating hospitals, units and clinicians have in the collection and preparation of data?20.Please tell me about the data infrastructure used in Michigan.How does it provide what you need to improve quality?What are its most important features?21.Was the data infrastructure planned and tested before the collaborative launched?Did you have a clear idea about what you needed in advance?How has it changed over time and why did it change?25.In your experience, what is unique or different about how data is collected and used in Michigan?26.Is data used to rank or compare participants in any way?Does this happen at the level of hospitals, units or individuals?Can sites or individuals compare their performance?Feedback 27.What information is fed back to participants?What aspects of quality or performance are highlighted as most important and why, e.g. are outcomes more important than process measures?How was this determined and what role did clinicians play?28.How is information fed back to participants?What are the key processes and activities?To whom and how frequently does feedback occur?At what levels are information presented, e.g.hospital, unit, individual?29.In what format is information fed back, e.g.use of visuals, text, numerical?How was this format developed?Who was involved in the process of developing this format?What role did clinicians play in developing it?30.To what extent is information customised for individuals?Does the information presented vary by type of personnel, e.g. between doctors and nurses?32.Is the approach to feedback in Michigan based on any particular theories?Was a particular approach to feedback planned from the beginning?33.In your experience, what is unique or different about how feedback happens in Michigan compared to elsewhere?Communication 34.What are the important communication principles and processes?What makes communication in Michigan effective?35.Is there direct communication between participants in the collaborative?How does this happen in practice?
The collaboratives publish a lot of their results as research papers.Was this a planned feature of the collaborative from the outset?Was this a rationale/incentive for setting up the collaborative in the first place?Why?52.What role does this academic approach play in conferring legitimacy for the collaborative's purpose and activities?Does the importance of this vary between participants, e.g. between program leaders and front-line clinicians?How does it vary?53.What role do research outputs play in creating and sustaining engagement and motivation among clinicians?BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) 38.In the beginning, how was it imagined that the collaborative would achieve that aim?What structures and processes were assumed to be important, and why?By what mechanisms were these intended to improve quality?39.Can you tell me how the collaborative was originally developed, and why it was developed in that way?What was the role of research evidence?40.Over time, did the way you sought to improve quality change?What changed and why?